As an eating disorder therapist, my goal is never to send someone away. My goal is to help you receive the level of support that gives you the best chance at healing and sustainable improvements in your health, safety and relationship with food, exercise and your body.
Sometimes weekly outpatient therapy is exactly what's needed. Other times, recovery requires more intensive support for a period of time.
Needing a higher level of care doesn't mean you've failed. It doesn't mean you're "sick enough," "too sick," or beyond help. It simply means that your eating disorder currently needs more support than can realistically be provided in one therapy session each week.
What Is a Higher Level of Care?
Eating disorder treatment exists on a continuum. The right level of care depends on many factors, including medical stability, nutritional needs, emotional safety, daily functioning, support, and the severity and longevity of eating disorder behaviors/symptoms.
Some of the more intensive treatment options include (listed in order of the most intensive to least intensive):
Inpatient Hospitalization
Inpatient care is the highest/most acute level of treatment and is generally reserved for individuals who are medically unstable or experiencing psychiatric emergencies that require around-the-clock medical supervision or intervention. This is what many think of as hospitalization. This setting could be needed when someone is having medical complications from their eating disorder or have comorbid health conditions. The primary goal of inpatient treatment is medical stabilization before transitioning to a less intensive setting for ongoing recovery work.
Residential Treatment
Residential treatment provides 24-hour support in a therapeutic living environment. In this scenario, the client lives at the facility but they are usually pretty medically stable. Clients participate in intensive individual and group therapy, nutritional rehabilitation, supervised meals/meal support, psychiatric care, and medical monitoring while temporarily stepping away from many outside responsibilities. This setting allows recovery to become the primary focus without the constant demands and triggers of everyday life. This is often recommended when a client needs to weight restore, has safety concerns, has struggled to break the cycle of consistent or frequent behavior use on their own. For example, if someone is bingeing or purging frequently at night, this setting would support breaking that behavior with removing access to binge, purge, or exercise. The emotional support to process what comes up for the client while not being able to engage in that behavior would also be a part of the treatment.
Partial Hospitalization Program (PHP)
PHP generally provides treatment for most of the day (for example 8am to 3pm), 5-7 days per week, while clients return home in the evenings. This level of care involves individual therapy, group therapy, nutrition counseling and education, psychiatric monitoring, and supported meals. It offers in the moment accountability and support with multiple meals/snacks, therapy, medical monitoring, and skill development. It can be especially helpful when eating disorder behaviors are becoming more frequent or when outpatient treatment is no longer creating meaningful progress.
Intensive Outpatient Program (IOP)
IOP typically involves a few to several hours of treatment, 3-5 days each week. Similar to PHP, clients often participate in individual therapy, group therapy, nutrition counseling, supported meals, and psychiatric care while continuing to live at home. This could look like a client living at home but going to a treatment program after work from 5pm to 8pm a few days a week. This level of care can be a good fit for someone who needs more structure than weekly therapy but is medically stable and able to hold themselves accountable in reducing some eating disorder behaviors outside of the program. This is often beneficial for clients to practice using skills and applying recovery to their daily life/while daily life stressors still arise.
When Might a Therapist Recommend a Higher Level of Care?
Every person is different, and treatment recommendations are never based on one number or one difficult week. Instead, I consider the overall picture and collaborate with a dietitian, psychiatrist and whole treatment team:
Some signs that a higher level of care may be beneficial include:
Medical instability or abnormal vital signs (if you want to learn more about the extensive list of the possible medical complications of eating disorders I HIGHLY recommend you check out this book https://www.sickenough.com/)
Rapid or ongoing weight loss
Inability to/stalled weight restoration in the outpatient setting for a variety of reasons
Frequent binge eating, purging, laxative misuse, restriction, or compulsive exercise that isn't decreasing in outpatient treatment
Increasing food restriction or inability to complete meals
Thoughts about food, weight, or body image consuming most of the day
Depression, anxiety, trauma symptoms, or obsessive thoughts making recovery difficult
Self-harm or suicidal thoughts requiring additional support
Feeling stuck despite consistently attending outpatient therapy.
Longevity - how long someone has been struggling with an eating disorder can play a role in how much structure, support, and radical change is needed to make sustainable progress.
Family members or loved ones struggling to provide enough support at home (this doesn’t mean they aren’t being supportive, it just means the individual might need more support than loved ones are ever going to be capable of or trained in providing)
There is a lot more nuance to the decision than hitting a few of the bullet points above. Just because you might hit a few of the points above doesn’t mean you automatically need a higher level of care AND you could still benefit from a higher level of care even if you don’t hit many of those bullet points.
Dietitians will use their own criteria (there could be a whole other blog about what medical criteria, clinical nutrition assessments, cardiac evaluations, lab results, caloric intake, need for weight restoration, frequency of purging etc that can constitute a higher level of care) and I am not a dietitian so I am not speaking to those here. Therapists will have their own considerations and criteria too. Some other things considered are the client’s motivation, home environment, what support they have (the number and quality of these supports in terms of their understanding of eating disorders and emotional availability), and ability to reduce their behaviors thus far.
It's usually not one crisis that leads to a recommendation. It's recognizing that the eating disorder has become stronger than the amount and kind of support currently available. Hear me when I say it is not because you are doomed or beyond help.
Symptom Swapping
Eating disorders can morph over time to try and be sustained in secret or resist boundaries set by others. When restriction is taken away from someone due to parents taking control of an adolescent’s food, they may lean more on exercise, when purging via self induced vomiting is taken away from someone via a lack of independence, they may turn to purging via laxatives or increased restriction. If someone can’t reduce one eating disorder behavior without replacing it with another, that could be a sign they need more support to develop other ways to cope.
Secrecy/Deception
Another thing to look for (that can be hard to spot) in regards to when a higher level of care might be needed, is secrecy with supports and the treatment team. If someone is hiding behaviors they previously were honest about or haven’t disclosed this is a sign more support and accountability might be needed for the client to make meaningful changes. This can look like throwing food out and lying about consuming it, exercising in secret, purging in secret, manipulating the scale, etc. I don’t expect someone to always be honest about their behaviors or even fully understand the extent or severity of them from the start, because that is part of eating disorders is minimization, isolation and secrecy, but if someone is going out of their way to engage in/hide behaviors and don’t feel comfortable disclosing this to their provider or supports, this might be a sign the eating disorder has significant power over the person’s actions and outpatient isn’t the most realistic setting to make significant changes.
Underlying Mental Health Conditions
Anxiety, depression, PTSD, and other mental health diagnoses are often comorbid with eating disorders. It is not uncommon that the eating disorder develops as a way to cope with these underlying mental health challenges and when eating disorder behaviors are reduced other mental health symptoms might spike. If someone’s anxiety significantly increases to the point of not being able to consistently cope with the reduction of ED behaviors, (an increase in anxiety/depression when taking away the eating disorder’s control is completely expected and normal by the way) that might also be a sign a higher level of care is needed to address the comorbid anxiety (or other mental health diagnosis) and eating disorder.
Zooming Out
Another thing to consider is how you want your life to look in 5, 10, and 20 years. If you are a college student, parent or athlete who can’t imagine taking time away from school or the social implications of leaving school, maybe ask yourself if you want to be dealing with this when you are trying to care for kids, go to graduate school, raise teenagers, or support yourself financially? Or if you were to continue functioning with the eating disorder how you are, would you be able to create the life you want?
One thing about eating disorders, is they shrink someone’s world to food, exercise and their body. They make those things feel like the most important things so it can be helpful to be forced to look beyond what the eating disorder values if you can. If you can’t…that might also be a sign a higher level of care could be beneficial.
Things to Ponder if You Find Yourself Considering if You Need a Higher Level of Care:
Has your eating disorder impacted your social life? Does it keep you from doing things you would like to do?
Have you been working on recovery with little to no progress over a sustained period of time?
Do you find yourself playing whack-a-mole with symptoms where one thing gets better but something else is getting worse?
Is your eating extremely rigid? Do you feel okay about your food/body and self when you are able to stick to the plan in your head but any variation from that causes a lot of stress?
Is how much or what you eat dependent on what exercise you did that day? Is your mood dependent on how much exercise you did?
This is by no means an all inclusive list and these don’t mean you do or don’t need more support, but they are things worth discussing with your therapist!
Why More Support Can Actually Accelerate Recovery
Many people assume that attending treatment means putting their life on hold and I will not deny that it can require significant sacrifices and you are allowed to grieve that! AND in reality, untreated or prolonged eating disorders often place life on hold far more than treatment ever does. When your brain is constantly calculating calories, planning the next binge, avoiding meals, compulsively exercising, or fighting urges, there's very little mental energy left for fostering relationships, work, parenting, school, or fun/hobbies all while delaying being able to engage in life the way you would hope.
A higher level of care creates the opportunity to interrupt that cycle.
Rather than trying to recover in isolation in the 167 hours between the 1 hour per week therapy sessions, you're surrounded by professionals and peers who are helping you actively practice recovery every day. That level of repetition matters in making sustainable and meaningful changes.
Recovery is so multifaceted.
It's about understanding why the eating disorder developed AND practicing new behaviors repeatedly while maintaining them with less and less external accountability (sometimes this means stepping down through the levels of care) until they begin to feel possible outside of treatment.
Common Reasons People Hesitate
Even when someone knows they need more support, pursuing treatment can feel incredibly difficult, overwhelming, and scary. Some of the most common concerns include:
"I'm not sick enough." or “It’s not that bad”
This is one of the hallmark thoughts of eating disorders. Many people believe they need to become "worse" before accepting help. Unfortunately, waiting often allows the illness to become more entrenched and there is never truly a point where you will feel “sick enough”. The bar is always moving and the eating disorder will always have another reason.
“My parents or partner don’t seem to think it's necessary”
I also see parents struggle with the idea of a higher level of care. No parent wants to have to send their kid away for any period of time AND it might be what is needed to set them up to have the skills to cope for their future. This can also go hand in hand with feeling not sick enough if family or friends don’t know the full extent of your struggles and the extensive medical/health risks of prolonged eating disorder behaviors, the client’s eating disorder might be assigning meaning to others not suggesting a higher level of care and drawing the conclusion that it must not be that bad.
“My doctor said I’m fine.”
Many medical providers receive very little to no training on eating disorders, so even caring, well-meaning physicians can underestimate how severe and complex they are. If your weight and vitals aren’t an immediate emergency, you may be told that everything looks fine or that you don’t need a higher level of care. Some people even get praised for their weight loss or exercise routine.
Stable vitals and lab results don’t necessarily mean you’re okay or that you don’t need more support. Eating disorders can be serious long before they show up as an emergency at a routine appointment. Your doctor’s input is an important piece of the picture AND it isn’t the whole picture, especially if they don’t specialize in eating disorders. If you’ve received this message from a provider, I encourage you to talk about it with your therapist or get an assessment from a provider or program that specializes in eating disorders.
"I can't leave work or school."
Stepping away from responsibilities can feel impossible. At the same time, continuing to function while your physical and mental health deteriorate often carries significant long-term consequences. Sometimes taking time to recover is what allows you to return more fully to the life you want.
"I'm worried about the cost."
Insurance coverage varies, and finances can absolutely be a real barrier. While treatment can be expensive, many programs have utilization review teams that help advocate with insurance companies, offer payment options, or connect individuals with financial resources when available.
"I don't want people to know."
There is still stigma surrounding eating disorders and mental health treatment. Many clients worry about judgment from family, employers, or friends. Remember that receiving treatment is a healthcare decision, not something you need to earn or justify.
"I'm afraid I'll lose control."
Eating disorders often rely on predictability and control. Entering treatment can understandably feel frightening because it involves trusting others. It's completely normal to feel ambivalent, and many people begin treatment while still feeling unsure.
If you want to learn more about more reasons why someone with an eating disorder might be hesitant to pursue treatment, read more about function of the disorder, societal factors and more here.
How Does it Work?
When you reach out to a higher level of care, they will schedule an assessment where they will do a thorough evaluation of your medical status, eating disorders symptoms, mental and physical health history and supports. Based on this assessment, they will recommend what level of care they think is appropriate/needed. This is not always going to be the highest possible level. I often hear clients say they fear they will be told to go to residential no matter what. That is not the case. They want to admit you to the level of care that allows you to keep as much of your regular life as possible while giving you the amount of support that will be needed to recover based on your assessment. They also have to prove to insurance companies that you meet criteria for insurance to cover you at that certain level of care (this has its own whole host of issues I could write many more articles on and the problems associated with this system) because insurance doesn’t want to pay for more intensive treatment than what they deem absolutely necessary.
One misconception is that entering treatment means disappearing for months. Most people move through different levels of care over time. Someone might begin with residential treatment, transition to PHP, then to IOP, and eventually return to outpatient therapy. Others may start and only need IOP for about 6 weeks before stepping back into weekly sessions.
Someone could start at PHP, not be following through on their meal plan at home, or be purging consistently when they get home from the program because they are so overwhelmed that more support is needed to prevent significant symptom swapping and they are stepped up to residential for a period of time. There is no one trajectory.
Virtual higher levels of care also exist. While virtual PHP/IOP was a wonderful development in the last several years to make more support more accessible to people all over the country and in rural communities, it might not be the right fit for everyone. For someone who has low internal motivation for recovery, a significant amount of weight restoration to be done, lack of support at home, or engaging in deception, it might be better to be in person so there is more accountability around engaging in groups and meals.
It truly depends on the person and their situation. Treatment is designed to provide the amount of support you need right now to eventually get you back to your life.
My Role as Your Therapist
If I ever recommend a higher level of care, it isn't because I believe you're failing. It's because I care deeply about your safety and your long-term recovery and based on my training and clinical experience working in both higher levels and outpatient level of care, you would be either safer and/or more supported and successful in making the changes you want to see at a higher level. I might be seeing that progress is not feeling consistent enough to make outpatient the appropriate level, I might be concerned about your ability to sustain recovery behaviors outside of the supervision of parents or loved ones, I might see you have been stuck in this place in your eating disorder and need some more external accountability for a short period of time to get unstuck, I might be worried about your physical health want more eyes on you like nurses, psychiatrists, and dietitians.
If a higher level of care is recommended, I would help coordinate referrals, communicate with treatment teams, and support you throughout the process.
I do not take lightly the sacrifice it takes to leave your daily life behind and attend a program at any level of care AND I also believe that as a clinician, I am not doing my clients any favors by shying away from these conversations even if it is something they do not want to hear. Sometimes therapy is about having the difficult conversations.
Recovery is rarely a straight line. Sometimes it requires increasing support before stepping back into outpatient therapy. Asking for more help isn't giving up. Often, it's one of the bravest and most effective decisions someone can make.
This turned into a longer than anticipated article because there is so much that goes into a decision like pursuing a higher level of care. I hope one takeaway is that it is so nuanced. Like most things in therapy and dealing with humans, the answer is, IT DEPENDS! I want to be clear that this is going to look different for each person based on their unique story, recovery, emotional and financial support, genetics, and sadly even access to care!! This is also why it is important to have a therapist you trust to navigate these decisions with.
Looking for Eating Disorder and Body Image Therapy in Philadelphia or Pennsylvania?
Whether you're just beginning to question your relationship with food or wondering if outpatient therapy is still the right fit, you don't have to navigate those decisions alone.
I provide virtual eating disorder therapy for adults across Pennsylvania, New Jersey, Delaware, Vermont and Ohio and help clients determine the level of support that best meets their current needs. If outpatient therapy is appropriate, we'll work together toward lasting recovery. If additional support would be beneficial, I'll help you understand your options and guide you through the referral process with compassion and without judgment.
Recovery isn't about proving you're "sick enough." It's about getting the support you need to build a life that's no longer controlled by your eating disorder. Recovery is possible, and you don't have to walk that path by yourself. Contact Paige to start healing your relationship with food and your body!
Paige Thompson is a Licensed Professional Counselor and eating disorder and body image therapist with several years of experience treating individuals with eating disorders in the partial hospitalization, intensive outpatient, and outpatient levels of care. Learn more about Paige here!